Toothache
If you don't know the answer just leave it blank
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Name
*
First Name
Last Name
Can you pinpoint the pain to one tooth, or is it an area?
One Tooth
An Area
Does it feel like a top or bottom tooth
Top
Bottom
Is it left or right?
Left
Right
Back or front tooth (back teeth are the molars)
Back
Front
Back
Next
Pain Symptoms
When did you first feel symptoms/when did everything start?
Has it been getting worse since then? Or stayed constant/comes and goes but stays about the same intensity?
Getting Worse
Constant
Comes and goes
Is there swelling?
Yes
No
Has it been keeping you up at night?
Yes
No
Have you taken pain killers for the symptoms?
Yes
No
Did the painkillers provide significat relief?
Yes
No
How would you rate the pain at its worst?
Mild
1
2
3
4
5
6
7
8
9
Excruciating
10
1 is Mild, 10 is Excruciating
How would you describe the pain?
aching
throbbing
sensitive
sharp
tender
dull ache
shooting
burning
Other
Does anything make it worse?
cold
hot
sweet
biting
chewing
laying down
Other
Does anything make it better?
If it is a tooth, would you like to try to save the tooth if possible?
Yes
No
Submit
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